If in office, by signing below, I have given my consent for treatment by the medical provider to provide medical treatment including the administration of injections and superficial procedures.  I am responsible and expected to pay Leo Express Medical Care the required payment. I further agree that I will be responsible for all collection costs, including legal fees and court costs should my account be referred to an attorney or collection agency for non-payment. I understand that by signing below I also authorize the release of any medical information necessary to pay the claim. This assignment of benefits will remain in effect until revoked by me in writing. 

The medication is FDA-approved for weight loss or being prescribed off-label under clinician guidance.

Weight loss medications are to be used in conjunction with diet and exercise.

Potential side effects may include nausea, increased heart rate, dry mouth, constipation, or others depending 

on the drug. Regular follow-ups and lab work are required to monitor safety. Medication may be discontinued if 

ineffective or side effects are intolerable.

• You have a right to:
  
• Know the qualifications of your healthcare provider.
• Receive clear and accurate information about the proposed weight-loss program.
• Know the risks associated with any medications, supplements, or procedures.
• Be informed about fees and costs in advance.
• Understand that rapid weight loss may pose health risks and must include a diet and exercise plan.
• Be provided with a copy of this statement before the program begins.
  

NOTICE: Weight loss should be achieved through a healthy diet, physical activity, and behavioral change. Weight-loss medications or supplements must be FDA-approved or being prescribed off-label under clinician guidance